B 3411 
G82 
;opy 1 



P ' 



No. 54 



THE ARGUMENT FOR MEDICAL 
INSPECTION OF SCHOOLS 

AND 

SIGNIFICANT FACTS ABOUT MEDICAL 
INSPECTION 



REPRINTED FROM 

MEDICAL INSPECTION OF SCHOOL 

BY 

LUTHER HALSEY GULICK, M. D. 

AND 

LEONARD P. AYRES, A. M. 



Department of Child Hygiene 

Russell Sage Foundation 
I Madison Avenue, New York City 



i;i;«*ci: 



srf 






V^V 



Significant Facts 



Medical Inspection " is founded on a recognition of the close connec- 
tion which exists between the physical and mental condition of the child- 
ren and the whole process of education." It " seeks to secure ultimately 
for every child, normal or defective, conditions of life compatible with 
that full and effective development of its organic functions, its special 
senses, and its mental powers, which constitute a true education." — (Eoc- 
traci from Memorandum 0} British Board of Edtication.) 

Medical Inspection is a movement national in scope in England, 
France, Belgium, Sweden, Switzerland, Bulgaria, Japan, the Argentine 
RepubHc, and practically so in Germany. In the United States seventy 
cities outside of Massachusetts, and all the cities and towns of that state, 
have systems of medical inspection. 

Massachusetts has a compulsory medical inspection law. New 
Jersey has a permissive one, Vermont a law requiring the annual testing 
of the vision and hearing of all school children, and Connecticut one 
providing for such tests triennially. 

As a rule, the work of medical inspection is underpaid in America. 
In England such services are compensated at the rate of from $1500 to 
$4000 per annum, while in America $200 has, in many quarters, come 
to be regarded as a standard salary for the services of the school phy- 
sician. 

Systems themselves vary so widely in scope and thoroughness here 
in America as to range in annual per capita cost from half a cent to a 
dollar and twenty-two cents. 



2 Medical Inspection of Schools 

Clear distinction must be made between medical inspection solely 
for the detection of communicable disease and that physical examination 
which aims to discover defects, diseases, and physical condition. The 
one relates primarily to the immediate protection of the community, 
while the other looks to securing and maintaining the health and vitality 
of the individual. 

Medical inspection for the detection of contagious diseases can be 
adequately performed at an annual cost of about fifteen cents per capita, 
while physical examinations similarly performed, and including the in- 
spection for the detection of communicable diseases, cost about fifty 
cents. 

Effective medical inspection for the detection of communicable 
diseases can only be conducted by the Department of Health, or at least 
with its active co-operation, because of the necessity for legal authority 
for protecting the community, not only during epidemics of contagious 
diseases, but also to prevent them. 

Effective physical examination can only be conducted by the Board 
of Education, or at least with its full co-operation, because it involves the 
following of the child from grade to grade and year to year. It involves 
the constant attention of the teacher with reference to seating the deaf 
where they can hear best, and those having poor vision where they can 
see best, as well as constant co-operation with the parents. 

Physical examinations can be well made by an experienced school 
physician in from twelve to fifteen minutes per child. Vision and hear- 
ing tests demand from three to five minutes per child. 

The conduct of medical inspection is such a technical matter and is 
so different from the work done by the practising physician as to demand 
special training and experience. 

Investigations so far indicate clearly that physical defects of children 
decrease with age. That is, taking into consideration a sufficiently 
large number of cases, children of fourteen years of age show fewer de- 
fects than do those of thirteen years, and these, in turn, fewer than those 



Significant Facts 3 

of twelve years. Hence older children have fewer defects in whatever 
grades they may be found, and so, from the very definition of the term, 
retarded children in any given grade have fewer defects than children 
of normal age in the same grade. This fact is in direct contradiction 
not only to the prevailing opinion, but also to the conclusions that have 
been emphasized in current professional discussion to the efifect that 
children behind their grades were so because of the handicap imposed 
on them by physical defects. This important fact should not in any 
way lessen our endeavors to bring the aid of medical science to the ser- 
vice of the physically handicapped. It should rather give us renewed 
hope, for we find that the direct tendencies of normal growth make to- 
ward rather than away from those wholesome physical conditions that 
it is the aim of every physician and every educator to bring about. 

Physical defects are not equally significant either from the medical 
or from the pedagogical standpoint. It is unfair and tends toward mis- 
leading conclusions to include in the same classification pediculosis and 
defective vision, club-foot and defective hearing, adenoids and ring 
worm. Therefore the effects of each kind of defect should be separately 
studied — e. g., the effects of defective vision, hearing, adenoids, carious 
teeth, etc., upon school progress and upon health. 



CHAPTER II 

The Argument for Medical Inspection 

Since the days of Juvenal, men have been quoting his much abused 
half-Une, "A sound mind in a sound body"; and while making diligent 
provisions for schools in which "sound minds" were to be shaped, have 
felt that these schools needed little scrutiny as to their fitness for con- 
serving and developing "sound bodies". 

The famous Spanish voyager who lost his life in his futile search 
for the phantom fountain of youth was far from being the first or the 
last of the long line of seekers for a "cure-all" which should eradicate 
the ailments of old age and restore that buoyant health of youth which 
modern science is just beginning to teach us must be diligently con- 
served from childhood, if it is to be enjoyed in after-life. 

To say that we have during all this time lost sight of the true source 
of a healthy old age would be an extreme statement, but it is certainly 
true that educators in general have given but scanty and fleeting atten- 
tion to the problem of the physical well-being of their charges. 

All too often the same complacent and care-free attitude of mind 
has been shared by the parent. All children had to have the " common 
children's diseases" — and the sooner, the better. If Johnny breathes 
through his mouth — "He always did that. He will outgrow it." The 
child's cough is only "a slight cold." "He always turns his head to 
one side when he writes or reads. It's a habit he has got into. He 
has always been pale. It is nothing unusual." 

In cases of serious epidemics it has always been recognized that 
parents have the right to insist that the schools shall be safe places 
for them to send their children. This right has been recognized by the 
closing of the public schools during an epidemic; but despite the fact 
that it has long been recognized that the public school serves as a center 
of exchange for contagious diseases which pass from pupil to pupil, 

4 



The Argument for Medical Inspection 5 

the occasional closing down and the rare fumigation have constituted 
the sum total of preventive measures, with the single exception of the 
commonly insisted on requirement of vaccination. 

Again, except in extreme cases, the school has taken Httle note of 
such defects of mind and body as might vitally affect the chances of 
success and happiness of the child, unless such defects were of the more 
directly alarming nature of contagious diseases. 

The "lockstep" has been the rule in physical matters, as in the 
realm of the course of study. All the children have been received on an 
equality and have been treated equally, no matter what their mental 
endowments or physical condition. The quick and the slow, the sound 
and the sick, have been grouped together; and he who could not keep 
his place in his studies has been as unquestioningly left behind as has 
he who through illness could not retain his place in the school. 

That such a course was poor business policy, based on the false 
assumption of a universal mental and physical equahty which does not 
exist, has been pointed out times without number. As in all movements, 
the leaders have been far in advance of the rank and file; and in our 
own, as in other countries, the great majority of people have been too 
much engaged in their special interests to give heed to the great problems 
involved in the work of improving the educational and physical well- 
being of the young of the race. 

With the great changes which have been coming over American 
life, former conditions have disappeared and this undisturbed indifference 
has become impossible. We have changed from an agricultural people 
to a race of dwellers in towns and cities. The school year has changed 
from a three months' winter term to one of five hours per day for ten 
months during the year. The number of years of school life has greatly 
increased. We have passed compulsory education laws. Going to 
school has become not only the normal, but the required occupation 
of all children for a considerable number of years. 

The results of these changed conditions on the health of children 
have become so marked as to insistently demand attention. The 
parents, school authorities, and health authorities have been unable 
to avoid recognizing the fact that in the nature of the case the school 
has become the most certain center of infection in the commimity. 

From these conditions grew up medical inspection, for the purpose 



6 Medical Inspection of Schools 

of detecting cases of contagious diseases and of segregating such cases 
for the protection of other children. Wherever established, the good 
results of medical inspection have been evident. Epidemics have 
been checked or avoided. Improvements have been noted in the 
cleanliness and neatness of the children. Teachers and parents have 
come to know that under the new system it is safe for children to con- 
tinue in school in times of threatened or actual epidemic. 

But medical inspection does not stop here, nor has it limited its 
activities to the field outlined. Other problems have been insistently 
forcing themselves on the attention of school men; and they, knowing 
something of the wonderful advances made in the field of medicine, 
have turned for aid to the physicians. 

With the changes in the length of the school term and the increase 
in the number of years of schooling demanded of the child, has come 
a great advance in the standards of the work required. When the stand- 
ards were low, the work was not beyond the capacity of even the weaker 
children; but with close grading, fuller courses, higher standards, 
and constantly more insistent demands for intellectual attainment, 
this has changed. Pupils have been unable to keep up with their classes. 
The terms "backward", "retarded", "exceptional" as applied to school 
children have been added to the vocabularies of the school men. In- 
quiries have been instituted into the causes underlying the phenomena 
of backward and retarded children, of those who are unable to keep up 
with their classes, or those who seem to be different from their com- 
panions in their ability to do the work demanded. 

As a result of these inquiries, physical examinations have been 
conducted by the doctors connected with the schools. Surprising num- 
bers of children have been found who through defective eyesight have 
been seriously handicapped in their school work. Many are found 
to have defective hearing. Other conditions are found which have 
a great and formerly unrecognized influence on the welfare, happiness, 
and mental vigor of the child. Attention has been directed to the 
real significance of adenoids and enlarged tonsils, of swollen glands 
and carious teeth. 

Persistently, earnestly and quietly this work has been pushed to a 
successful experimental accomplishment, and as a result we have to-day 
medical inspection in its various forms — not only for the detection of 



The Argument for Medical Inspection 7 

contagious disease, but also for discovering those physical defects 
which interfere with the child's ability to do his school work, or which, 
if neglected, will seriously affect his physical efficiency in after-life. 
The movement as a whole constitutes both a sign and a result of the 
gradual awakening which has developed into a wave of interest in 
matters that pertain to the health of school children that is now sweep- 
ing over the civilized world. 

Communities are seeing the whole matter in a new light. Gradually 
they are beginning to ask — not whether they can afford to take steps 
to safeguard in schools the welfare of their children, but whether they 
can afford not to take such steps. The realization is dawning that it 
is unbusinesslike to count carefully the cost of the school doctor, but to 
disregard the cost of death and disease, of wrecked hopes and dependent 
families. 

Teachers and parents are commencing to realize that from their 
viewpoint and from that of the school physician the problem of the 
pupil with defective eyesight may be quite as important to the com- 
munity as that of the child who has some contagious disease. This 
child, placed in a school where physical defects are unrecognized and 
disregarded, is unable to see distinctly, and headaches, eye-strain, and 
failure follow all his efforts at study. He cannot see the blackboards 
and charts, printed books are indistinct or are seen only with much 
effort — everything is blurred. Neither he nor his teacher knows what 
is the matter, but he soon finds it impossible to keep pace with his 
companions, and, becoming discoiu^aged, he falls behind in the unequal 
race. 

In no better plight is the child suffering from enlarged tonsils and 
adenoids, which prevent proper nasal breathing and compel him to 
keep his mouth open in order to breathe. Perhaps one of his troubles 
is deafness. He is soon considered stupid. This impression is strength- 
ened by his poor progress in school. Through no fault of his own 
he is doomed to failure. He neglects his studies, hates his school, 
leaves long before he has completed the course, and is well started on 
the road to an inefficient and despondent life. 

Public schools are a public trust. When the parent delivers his 
child to their care, he has a right to insist that the child under the super- 
vision of the school authorities shall be safe from harm and will at 



8 Medical Inspection of Schools 

least be handed back to him in as good condition as he was at first. 
Not only has the parent the right to claim such protection, but even 
if he does not insist upon it, the child himself has a right to claim it. 
The child has a claim upon the state and the state a claim upon the 
child which demand recognition. In the words of Dr. William H. 
Allen: "When the state for its own protection compels a child to go 
to school, it pledges itself not to injure itself by injuring the child." 
We are beginning to find out that many of our backward pupils are 
backward purely and simply because, through physical defects, they 
are unable to handle the work of the school program. What these 
defects are and the causes that lie behind them are things that we must 
know. If we do not know them, we must find them out and guard 
against them. Education without health is useless. It would be better 
to sacrifice the education if, in order to attain it, the child must lay 
down his good health as a price. Education must comprehend the whole 
man and the whole man is built fundamentally on what he is physi- 
cally. Children are not dullards or defectives by the will of an inscru- 
table Providence, but rather by the law of cause and effect. 

The objection that the state has no right to permit or require medical 
inspection of the children in the schools will not bear close scrutiny nor 
logical analysis. The authority which has the right to compel attendance 
at school has the added duty of insisting that no harm shall come to those 
who go there. The Massachusetts law, with its mandatory "shall," is 
certainly preferable to the New Jersey law, with its permissive "may." 
The exercise of the power to enforce school attendance would be dan- 
gerous if it were not accompanied with the appreciation of the duty 
of seeing that the assembling of pupils brings to the individual no physical 
detriment. When the subject is considered both from the standpoint 
of the individual and from that of the state, the wonder is not that 
medical inspection is now being agitated, but rather that it was not 
long ago put into practice. 

Nor is the state, in assuming the medical oversight of the pupils 
in the public schools, trespassing upon the domain of private rights and 
initiative. American systems do not, like the feeding of school children 
(already resorted to in France and in parts of England), lessen the respon- 
sibility of the parent or tend to weaken or supersede the home. Under 
medical inspection absolutely nothing is done for the parent but to tell 



The Argument for Medical Inspection 9 

him of the needs of his child, of which he would otherwise have been 
in ignorance. It leaves it to the parent to meet those needs. It leaves 
him with a larger responsibility than before. Whatever view be taken 
of the right of the state to enforce measures for the correction of defects 
discovered, the arguments for and against do not enter into the present 
discussion. It seems difl&cult to find a logical basis for the argument 
that the state has not the right to inform the parents of defects present 
in the child, and to advise as to remedial measures which must be taken 
to remove them. 

The justification of the state in assuming the function of education 
and in making that education compulsory is to insure its own preserva- 
tion and efl&ciency. Whether or not it is to be successful will depend 
on its individual members. But the well-being of a state is as much 
dependent upon the strength, health, and productive capacity of its 
members as it is upon their knowledge and intelligence. In order that 
it may insure the efficiency of its citizens, the state through its compulsory 
education enactments requires its youth to pursue certain studies which 
experience has proved necessary to secure that efficiency. Individual 
efiiciency, however, rests not alone on education or intelligence, but is 
equally dependent on physical health and vigor. Hence, if the state 
may make mandatory training in intelligence, it may also command 
training to secure physical soundness and capacity. 

Much time may elapse before there will be brought to bear in all 
schools the measures, now so successfully pursued in some, for conserv- 
ing and developing the physical soundness of rising generations. But, 
nevertheless, the movement is so intimately related to the future welfare 
of our country and is being pushed with so great energy and earnestness 
by its advocates that it is destined to be successful and permanent. 

Not alone our unwillingness to be outdone in this public service 
by foreign nations, not alone our sense of practical foresight, but our 
inherent feeling of obligation toward our children and oiu* recognition 
of this service as one of necessity for the national well-being, are forcing 
upon us the incorporation of this phase of public activity as an integral 
part of our public education. 



LIBRARY OF CONGRESS 



020 313 754 

Russell Sa^e Foundation Publications 



MEDICAL INSPECTION OF SCHOOLS 

BY LUTHER HALSEY GULICK, M. D. 

Director op Physical, Training op the New York Public Schools; and 

LEONARD P. AYRES. A. M. 

Formerly General Superintendent op Schools for Porto Rico 

Some Opinions 

"Lucidly exhaustive and admirably arranged." — The Nation. 

"A notable contribution both to medicine and to school administration." — 
Erie Dispatch. 

"Of large practical utility." — Rochester Times. 

"The book is most complete and valuable." — 5. W. Newmayer, M. D. 

"An important contribution to the cause of Education." — Jotirnal of Education. 

"The appearance of this most timely book is cause for genuine satisfaction."— 
Charities and the Commons. 

Third Edition. Price postpaid, $1.00 



LAGGARDS IN OUR SCHOOLS 

A Study of Retardation and Elimination in City School Systems 

BY LEONARD P. AYRES, A. M. 

Formerly General Superintendent of Schools for Porto Rico and Chief of the 
Division of Statistics of the Insular Department of Education, Secretary 
of the Backward Children Investigation of the Russell Sage Founda- 
tion. Co-AuTHOR of Medical Inspection of Schools, etc. 

"I shall use it in my course in child. psychology in the University of Pennsylvania 
next winter and expect to make it .the basis of the statistical side of the work for 
some years to come." — Lightner Witmer, Professor of Psychology, University of 
Pennsylvania. 

"The work is marked by logical sanity and absence of the hasty and extravagant 
generalization that one so often finds in sociological discussions." — Borden P. 
Bowne, Dean of the Graduate School, Boston University. 

"I have read the book with increasing satisfaction, and shall have still more 
satisfaction in using it in my classes during the coming year as an illustration of 
what an investigation in school administration really means." — Paul H. Hanus, 
Director Division of Education, Harvard University. 

"Mr. Ayres has given life to his figures and character to his diagrams." — 
American Industries. 

"Such a book, at once readable and scholarly, scientific and popular, critical 
and constructive, is typical of the best in educational literature." — The Independent. 

" It is the most important specific study of school conditions that has been made 
by any one." — Journal of Education. 

Second Edition. Price postpaid, $1.50 



CHARITIES PUBLICATION COMMITTEE 
105 East 22d Street, 
New York City, N. Y. 



J-'BRARY OF 



CONGRESS 



0020137540 



HoUinger Corp. 
pH8.5 



